Friday, November 1, 2013

Times of change and opportunity: Towards a psychological model of mental health and well-being

Notes
for a speech given at: The International Psychology Conference, Dubai 1st November 2013.
These are my NOTES for the speech, the speech as delivered may have been different (in particular, I did suggest that we needed to lead "a revolution" in our approach to these issues, which doesn't appear below).

Good morning,
and thank you for inviting me.

It is a time of
significant change in the field of mental health.

Over the past
twenty years or so, we’ve seen a very positive and welcome growth of the user
and survivor movements, some first signs of more responsible media coverage,
and a rejection of the idea that we should be stupefied by shame and stigma
into accepting the paternalism of earlier days – we are just starting to see
the beginnings of transparency and democracy in mental health care.

The publication
of DSM-5, the fifth edition of the American psychiatric diagnostic manual, has
proved controversial, and has led many to question the creeping medicalisation
of normal life, and to criticise the poor reliability, validity, utility and
humanity of conventional psychiatric diagnosis.

At the same
time, we have seen many commentators conclude that there is precious little
reason to believe some of the more outrageous claims as to the effectiveness of
many psychiatric drugs. We know that these drugs have very significant adverse
effects, too. And there is even less reason to believe that these drugs are
effective in the longer term – whatever their benefits in emergencies.

On the other
hand, we have seen growing evidence of the effectiveness of evidence-based
psychological therapies, helping people with a wide range of problems.

All this has
led many to call for radical alternatives to traditional models of care.

I agree.

But I would
argue that we do not need to develop new alternatives.

We already have
robust and effective alternatives… we just need to use them.

The
well-established ethos of the clinical psychologist as ‘scientist-practitioner’
means that we can offer evidence-based scientific models of mental health
problems and well-being.

These integrate
biological findings with the substantial evidence of the social determinants of
health and well-being, mediated by psychological processes.

For example,
colleagues and I found – in research conducted with the support of the BBC –
that negative life events were substantial contributors to a person’s levels of
depression and anxiety, but this was mediated by their level of rumination.

And, of course,
because these models almost inevitably refer to psychological mechanisms
mediating the effects of biological, social and circumstantial factors on
mental health problems and wellbeing, they almost inevitably imply that
psychological interventions – which affect these psychological mechanisms – can
be effective.

In simple terms,
if we were able to “turn off” our rumination, we’d be able to turn down at
least some of our depression and anxiety.

These
significant scientific and professional developments allow us to foresee a
future beyond the 'disease model' of mental health and well-being.

The Roman emperor
and philosopher, Marcus Aurelius (played by Richard Harris in the film
“Gladiator”) once argued that we need always to bear in mind: “What is this,
fundamentally? What is its nature and substance, its reason for being?”

What, then, is
the fundamental nature and substance of those psychological, emotional and
behavioural problems that are the subject matter of our profession?

In my view, they
are fundamentally social and psychological issues. They do have clear biological
elements – we should not artificially separate our physical from our mental
health. So psychologists, therapists and social workers must work closely
alongside GPs, public health physicians and nurses. But mental well-being is
fundamentally a psychological and social phenomenon, with medical aspects. It
is not, fundamentally, a medical phenomenon with additional psychological and
social elements.

Clinical
psychology is a wonderful profession – I’m proud to be a clinical psychologist.
But we have, I believe, been tempted down a medical route. We’ve tended to
think in terms of “disorder”, in terms of “aetiology” in terms of “treatment”
and in terms of “pathology” or “abnormality”. We conduct ‘randomised
controlled trials’, we set up programmes such as the UK’s “IAPT” – improving
access to psychological therapies programme – which is predicated on the notion
of identifying people with recognised ‘mental disorders’, offering ‘treatment’
and assessing outcome on the basis of quite traditional medicalised criteria. We
criticise this language, this way of thinking. But all too often, we use it.

We need to place
people and human psychology central in our thinking. And we need to return
to core principles – ethical, professional and scientific.

I went to a –
slightly odd – meeting recently where a very senior psychiatrist said: “… we’ve
got to remember, we’re paid to treat illnesses…” I simply disagree. That
may be the core purpose of some professions, but not mine… and perhaps not
medics’ either.

The World Health
Organisation describes health as “... a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity”. The
European Commission takes a step further, describing mental health as: “a
resource which enables them to realise their intellectual and emotional
potential and to find and fulfil their roles in social, school and working
life. For societies, good mental health of citizens contributes to prosperity,
solidarity and social justice”.

The European
Commission, interestingly, also suggests that: “the mental condition of people
is determined by a multiplicity of factors including biological, individual,
family, social, economic and environmental”. They cite the role of
“genetics, but also gender, personal experiences, social support, social status
and living conditions” in our mental well-being.

I agree. In
my view, good mental health is indeed: “a resource which enables them to
realise their intellectual and emotional potential and to find and fulfil their
roles in social, school and working life”. My role, my job, my profession,
is helping people fulfil their potential as human beings, not treating
illnesses. In fact, doctors – medical practitioners, psychiatrists – have
always prized an element of their profession that goes beyond merely treating
the patient and illness in front of them.

I’m an
unapologetic cognitive psychologist. And I recognise certain pretty clear
findings from psychological science. Our thoughts, our emotions, our
behaviour and therefore, our mental health are largely dependent on our
understanding of the world, our thoughts about ourselves, other people, the
future, and the world. Biological factors, social factors, circumstantial
factors - our learning as human beings - affect us as those external factors
impact on the key psychological processes that help us build up our sense of
who we are and the way the world works.

Of course, we
must address the issue of biology.

Every thought I
have involves a brain-based event. All learning involves changes in associative
networks, depolarisaion thresholds, synaptic biomechanics, even gene
expression.

My view is not an
anti-brain, anti-psychiatry, model. But I believe that my brain is a learning
engine – a biological system that is the servant of learning. I am not the
slave of my brain, my brain is the organ with which I learn. So of course
every thought involves brain-based activity. But this isn’t the same as
biomedical reductionism. Our biology provides us with a fantastically
elegant learning engine. But we learn as a result of the events that
happen to us - it’s because of our development and our learning as human beings
that we see the world in the way that we do.

Everybody recognises
that there are changes to the way that our brain functions which affect our
thinking, our moods, our behaviour. Most cultures in the world are familiar
with a range of chemicals – cannabis, alcohol, even caffeine – that affect our
psychological functioning because of the effects they have on our brain.

And it’s
perfectly reasonable to suggest that individual differences in people – even
differences as a result of genetic differences – will have measurable
influences on their behaviour and thinking in later life.

But I think
there’s a world of difference between acknowledging these influences and
accepting a ‘disease model’.

For two striking
reasons.

First, I believe
that the relative influence of biological factors is relatively small.

I need to clarify
this.

Every thought I
have ever had involves a biological event.

I have also been
involved in supervising research that used fMRI technology – functional
magnetic resonance imaging – to study regional blood flow during a
self-referential task. We found that specific areas of the brain were
associated with self-referential thinking, and that these areas were more
active in people seeking help for depression.

When we think –
for example – of ourselves, as opposed to thinking of another person, it’s
abundantly clear that specific neural pathways are involved. Since thought
involves neural signals in the brain, it’s hugely unsurprising that thoughts of
all kinds involves identifiable brain circuitry.

But identifying a
pathway to a particular though process does not imply that a pathological
mechanism has been found.

Logically, quite
the reverse seems a more parsimonious explanation – if a particular neural
pathway is found to be associated both with emotional and interpersonal
difficulties and a key psychological process, it makes sense to me to assume
that this is an important scientific finding that applies to us all, not just
those of us unfortunate enough to have somebody attach an ‘illness’ label to
our emotions.

This is not a
style of thinking compatible with the “disease model”.

Because every
thought must involve a neurological process, merely finding a neurological
correlate of emotional distress or psychological process isn’t the same as identifying
a pathology or an ‘illness’. Quite the reverse.

In addition, my
reading of the available literature suggests to me that the influence of
variance between people in biological terms has much less influence on their
subsequent emotional life than the variance between people in social and
circumstantial terms.

Just a couple of
examples.

In my department
at Liverpool, colleagues Ben Barr, David Taylor-Robinson and Alex Scott-Samuel together
with Martin McKee and David Stuckler demonstrated that around 1000 more people
killed themselves in the years between 2008 and 2010 than would have been
expected. They also found that the English regions with the largest rises in
unemployment had the largest increases in suicides, particularly among men.

Rather
differently, Richard Bentall and John Read have analysed the impact of
childhood trauma – abuse – on the likelihood of developing psychosis. In a
number of studies, they have concluded that childhood abuse more than doubles
the risk that you’ll develop hallucinations or delusional beliefs in later
life.

It seems clear
that social and circumstantial factors are significant.

There have been
relatively few studies directly comparing the relative contributions of biological
and social variables, but reviews of the relative contribution of negative life
events and abnormalities of the serotonin reuptake gene by Steven Reich and
colleagues suggest that while life events are associated with future
depression, the same can’t be said of serotonin reuptake gene differences.

It’s perhaps
noteworthy that proponents of biological reductionism occasionally make some peculiar
suggestions – suggesting to Bentall and Read, for example, that genetic
abnormalities might make kids vulnerable to BOTH abuse and psychosis, but that
the abuse wasn’t really the cause. And, of course, when the different alleles
of the serotonin reuptake gene are found to be less clearly related to
depression than might be thought, well, we’re told that new genetic
breakthroughs are likely “within months”.

But, we must, as
psychologists, remain clear-sighted as to HOW biological, and, for that matter,
social and circumstantial factors affect our mental health and well-being.

And, again, the
alternative to the ‘disease model’ is already with us. It’s already part of our
scientist-practitioner model, and already well-established within psychological
science.

Undergraduate psychology
students are introduced to the ancient Greek philosopher Epictitus, and his
ethos that “it isn’t events that upset us, but our interpretation of those
events”.

That fits with my
own findings that psychological processes mediate the impact of biological,
social and circumstantial factors on mental health.

And more generally,
it supports the notion that our thoughts, our emotions, our behaviour and
therefore, our mental health are largely dependent on our understanding of the
world, our thoughts about ourselves, other people, the future, and the world.
Biological factors, social factors, circumstantial factors - our learning as
human beings - affect us because those external factors impact on the key
psychological processes that help us build up our sense of who we are and the
way the world works.

In this view of
the world, of human nature, there is no real need to invoke the idea of
abnormality or disease, even of diagnosis – people are just making sense of
their world; developing complex, shifting, emotionally-laden frameworks of
understanding of the world. This is why psychologists tend to be sceptical
of diagnoses.

Our science is
robust and substantiable. And our therapies – even when appraised using the
standards of biological medicine – are demonstrably effective.

So... what are
the implications for the system of care?

This is perhaps
not the forum to outline the failings of modern psychiatry. But it seems
clear that we’re dealing with a slightly dysfunctional family. On the one
hand, biological psychiatrists such as Guze – author of “Biological psychiatry:
is there any other kind?” and the Nobel Prize-winning Eric Kandel suggest that
biological functioning is the ‘final common pathway’ for mental disorder and,
indeed, therapy.

And our own Nick
Craddock argues in his manifesto or ‘wake up call for British psychiatry’ that
there has been a “creeping devaluation of
medicine” in psychiatry. There is, Craddock and colleagues argue: “… a very real risk that as the understanding
of complex human diseases steadily increases, recent moves away from biomedical
approaches to psychiatric illness will further marginalise patients…” and
that “…Psychiatry is a medical
specialty. We believe that psychiatry should behave like other medical
specialties”. This is a precise recapitulation of a medical model of
psychiatry. Craddock and colleagues are also refreshingly clear in their
professional or political aspirations – “British
psychiatry faces an identity crisis. A major contributory factor has been the
recent trend to downgrade the importance of the core aspects of medical care”.

Craddock and
colleagues confidently expect that molecular biology and neuroscience will help
us understand the ‘pathogenesis’ of mental health problems, therefore confirm
the value of ‘biomedical explanations of illness’ and confirm the value of a medical
psychiatric profession. On the other hand, Pat Bracken and colleagues – in
the same forum as Nick Craddock – argue the opposite: that “…Psychiatry is not neurology; it is not a
medicine of the brain. Although mental health problems undoubtedly have a
biological dimension, in their very nature they reach beyond the brain to
involve social, cultural and psychological dimensions. These cannot always be
grasped through the epistemology of biomedicine”. And, of course, a phrase
often repeated in relation to the developments of DSM-5 is that such approaches
represent “the creeping medicalization of
normal life”.

Two pretty much
diametrically opposed perspectives.

Does this
matter?

It probably does.

I receive a fair
number of unsolicited letters. One read: "... Rather than engaging with
the patients on the ward, the staff instead shepherded them around like sheep
with bullying commands, threats of ‘jabs’ (injections), and removal to an acute
ward elsewhere in the hospital, if they did not co-operate. The staff also
stressed medication rather than engagement as a way of controlling the
patients. And the staff closeted themselves in the ward office, instead of
being out and about on the corridors and in the vestibule where they should
have been. The staff wrote daily reports on each patient on the hospital’s
Intranet system; these reports were depended upon by the consultant
psychiatrists for their diagnoses and medication prescriptions, but were
patently fabricated and false, because the staff had never engaged or observed
properly the patient they were writing about in their reports. The
psychiatrists themselves were rarely seen on the ward, and only consulted with
their patients once a week."

And I quote in
aid Professor Sir Robin Murray, writing as Chair of the recent ‘Schizophrenia
Commission’; “the message that comes
through loud and clear is that people are being badly let down by the system in
every area of their lives.”

So… what’s
needed?

Well… First….

1. Get the
message right – drop the ‘disease model’ and adopt a psychosocial model.

I realise this is
didactic, that I’m telling people how to think. But didactic messages from
medicine have been commonplace for years! (a very senior psychiatrist once,
quite pleasantly, stated that his medical education made him entirely competent
to do all the jobs of everyone in his team, including clinical psychologists,
nurses and social workers, but that they, of course, couldn’t do his!).

So… drop the
‘disease model’ and accept that these are psychosocial issues.

On twitter, a
colleague suggested I was proposing a ‘psychobiosocial model’.

I quite like
that.

Then...

2. Stop
diagnosing non-existent illnesses – a simple list of people’s problems
(properly defined) would be more than sufficient as a basis for individual care
planning and for the design and planning of services.

And….

3. Recognise our
role lies in supporting well-being, not treating illnesses. For my psychiatric,
medical, colleagues, this is a perfectly respectable medical role (think of the
role of General Practitioners and public health physicians, think of medical
care in pregnancy and the role of someone like the medical advisor to the
Manchester United Football Club squad).

4. Fourthly … and
perhaps more radically…. Stop pushing the drugs (or at least slow down). They
just simply don’t offer an effective and safe solution…. And here I would
appeal to the work of medical colleagues such as Dr Joanna Moncrieff and
others.

5. Offer
psychosocial services that aim for recovery and personal agency on the part of
the client. That means working with a wide range of community workers such as
social workers, social pedagogues, and psychologists in multidisciplinary
teams, and promoting social rather than medical solutions in the first
instance.

Of course, of
course, there should be one-to-one psychotherapy. But we should be doing what
we’ve always wanted to do - which is offering more fully holistic services. We
should be linking with Jobcentre Plus employment advisers who are delivering
what are effectively wellbeing interventions for people. We should be working
with the education services. And we should be working with the physical health
services. We should be working with employers, there’s plenty of evidence that
interventions aimed at improving people’s wellbeing, not curing their mental
illnesses but improving people’s wellbeing is productive for employers. We
should be working with community services and the wider civil society.

In each case,
scientifically elegant analyses of psychological processes leading to
interventions.

All such interventions
should all be evidence-based and delivered by qualified, competent
professionals. Decisions about what therapy or therapies should be offered to
whom should be based on a person’s specific problems and on the best evidence
for the effectiveness of the intervention, not on diagnosis, and individual
formulations should be used to put together an individualised package of care
suitable for addressing each person’s unique set of problems.

So there are a
number of psychosocial interventions that we should pursue in addition to standard
one-to-one therapies.

6. Where
individual therapy is needed, recognise that there are many effective,
evidence-based, psychological therapies available.

When I was first
qualified as a clinical psychologist, I was told that to talk to a service user
experiencing psychosis was “unethical”, as talking about their problems would
make them worse. We now have evidence-based psychological therapies
recommended for a wide range of so-called ‘disorders’ and – in my area of
speciality, such evidence-based approaches are recommended for all – 100% of
people experiencing psychotic phenomena such as hallucinations and delusions.

But this again
returns to the language and thinking style of medicine – diagnosis, treatment,
outcome. We need to accept that a focus on social determinants of
well-being means that we are discussing what is effectively a social and
psychological phenomenon, with medical aspects, not a medical phenomenon with
social correlates

And this means…

7. In the
multidisciplinary teams delivering these services, medical psychiatric
colleagues should remain valuable colleagues. An ideal model for
interdisciplinary working would see leadership of such teams determined by the
personal qualities of the individual members of the team. It would not be
assumed that ‘clinical primacy’ would inevitably put our medical colleagues in
a position of unquestioned authority – people should regard themselves as
consultants TO the team, not leaders OF the team.

This does have
implications. It could mean a much greater reliance on GPs and other primary
care colleagues as opposed to what are not ‘traditional’ psychiatrists. We
might see joint working between GPs and community teams, with GPs offering the
medical input when needed – as opposed to seeing psychiatrists serving this
role.

And that might
not only be beneficial for the service user, but could see a massive cost
saving for the NHS, if this fed through to a commensurate reduction in our
dependence on highly expensive psychiatrists.

And this
principle could apply in residential care, too…

8. When people
are in crisis, residential care may be needed, but this should not be seen as a
medical issue. Since a ‘disease-model’ is inappropriate, it is inappropriate to
care for people in hospital wards; a different model of care is needed.
Residential units, again, should be based on social, not medical, models.
Residential social workers or nurses may well be the most appropriate people to
be in charge of such units. The nature of extreme distress means medical
colleagues may well be valuable members of the team but again they should be
consultants TO the ward, not having sapiential authority OVER the team.

As part of the
process of accessing these residential units…

9. When the
powers of the Mental Health Act are needed, the decisions should be based on
the risks posed to self and others, but also on the person’s capacity to make
decisions about their own care. This approach is the basis for the law in
Scotland, and the law in England and Wales permits the ‘responsible clinician’
to be a psychologist, nurse, or social worker. This should be routine. When we
reject a ‘disease-model’ of care and adopt a ‘human-centred’ model, the law
relating to mental health could change significantly; with different legal
criteria, different ways of assuring that people are offered ‘least restrictive
alternatives’, with a psychosocial focus, new roles for new professions, and a
greater focus on social justice and judicial oversight.

That doesn’t mean
“design medical teams for psychiatry, manage them out of hospital-based,
NHS-based Trusts but put them in a building away from the hospital site”, it
means locate the whole service in community services – put the service entirely
under local authority control. In the UK, we have the model of public health
(transferred to local authority control) to build upon. This should – and could
then be – under democratic local governance. I recognise that some local
authorities – especially, perhaps, in developing countries, may not yet be
robust enough for the task, but this should be the vision and aspiration,
rather than aiming for a medical model.

Adopting this
approach would result in much lower reliance on medical interventions, and a
much greater reliance on social and psychological interventions. We would – we
may as well be honest – need fewer psychiatrists. As we see a move towards
community-based social services, we would look to primary care (General
Practice - GP) colleagues for much of the necessary medical consultation and
input; linking psychological care to the wider well-being of patients in the
community. We would, in contrast, require much greater emphasis on, training
in, and staffing of, psychosocial approaches. What I’m proposing would be a
very major revolution in psychiatric practice. It would challenge the central
tenets of at least some traditionalist, biological, psychiatrists – and the
knock-on implications for social psychiatrists (who might otherwise share Pat
Bracken’s views and therefore otherwise be sympathetic) could be equally
significant as their power and authority is challenged.

In such a
vision…. Where are psychologists and what is our role?. Well… In my view, good
mental health is indeed: “a resource which enables them to realise their
intellectual and emotional potential and to find and fulfil their roles in
social, school and working life”. My role, my job, your profession, is helping
people fulfil their potential as human beings, not treating illnesses.

I believe that
our thoughts, our emotions, our behaviour and therefore, our mental health is
largely dependent on our understanding of the world, our thoughts about
ourselves, other people, the future, and the world. Biological factors, social
factors, circumstantial factors - our learning as human beings - affect us as
those external factors impact on the key psychological processes that help us
build up our sense of who we are and the way the world works.

It naturally
follows that psychologists should play a central role. We should offer
leadership – with colleagues such as Pat Bracken, Phil Thomas, Jo Moncrieff and
Sami Timimi; psychiatrists proud of their profession and expert medical
practitioners who nevertheless share these points of view.

But most
importantly, we should lead in the process of change. I invite you to think about
how we might work to make this kind of vision a reality.

Some steps might
appear hugely ambitious – I am recommending that local authorities, not
hospital Trusts, are the right home for psychiatry. You might think that the
opposition to that might be overwhelming. And you might think that it would be
impossible to achieve.

But we’ve
recently seen public health services transferred from NHS responsibility to
local authority management – a wholesale transfer, in my opinion placing public
health where it should be – and under democratic control – and, significantly,
meaning that local authorities now employ doctors and deliver clinical
services. I believe psychiatry should follow them. So… perhaps this relies on
the political and managerial activity of local Health and Well-Being Boards and
the management teams of Trusts… but it’s certainly not impossible.

And we’ve seen
some public and influential psychiatrists recently arguing that it’s dangerous
to abandon the current diagnostic tools – despite their acknowledged and
admitted flaws – because we have no proven alternative. The argument – the
incorrect argument – is that the critics of diagnosis would need to develop a
new technology of classification, which would then need to be counter-tested
against diagnosis, before we could take the dangerous – in their view – step of
abandoning the ‘disease-model’ approach.

Not true. It’s
forgivable for people with no perspective other than a ‘disease-model’,
‘diagnosis-treat’ approach to look within medicine and see… diagnosis and
nothing more. But I am – we, as clinical psychologists, are – applied
scientists.

We use the basic
principles of applied science. The Oxford English Dictionary defines the
scientific method as: "a method or procedure that has characterized
natural science since the 17th century, consisting in systematic
observation, measurement, and experiment, and the formulation, testing, and
modification of hypotheses."

So we use
operational definitions of relevant concepts. We develop hypotheses. And we
collect data. We don’t need to meet the challenge of a new technological
alternative to diagnosis and the “disease model”. We’ve had it since the 17th
century.

So it is time for change.

It is time to
remember – and act up to – out core purpose as psychologists.

Psychological
health and well-being is “... a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity”…. and “a
resource which enables citizens to realise their intellectual and emotional
potential and to find and fulfil their roles in social, school and working
life”.

Our thoughts, our
emotions, our behaviour and therefore, our mental health are largely dependent
on our understanding of the world, our thoughts about ourselves, other people,
the future, and the world. Biological factors, social factors, circumstantial
factors - our learning as human beings - affect us because those external
factors impact on the key psychological processes that help us build up our
sense of who we are and the way the world works.

Our particular
role is to use the well-tested tools of science to understand this process and
to intervene to help people improve their lives.

Change
is needed, but it’s also a return to our core purpose as a profession.

I appreciated Peter's fine work and his proposal for new concept on mental healthcare and well-being approach. The paradox here is that, like all illness has to be scaled on merits and causes. After a patient holistic assessment, the doctor or whoever is the assessor has to determine the area that trigger the illness, it could be biological, social, economical, environmental and psychological. I believed that treatment should be targeted on that area not using one model for all patients.

Hi Peter k boss this marvelous blog given by you.starting with insofar in pshycothewrapy drugs and it's adverse feedback, the report of Dsm-5 in pshcotherpy and give your openion chose the robust and effective alternative in pshycotherapy.agrre with you the biological[nature] factor is one ost important impact in MHP and this can be good approaches by clinical pshycology controlled trial.